title: Benefit of early sustained reperfusion in patients with prior myocardial infarction (the GUSTO-I trial). Global Utilization of Streptokinase and TPA for occluded arteries.
abstract: The primary objective of this study was to characterize a large cohort of patients receiving thrombolytic therapy for acute myocardial infarction with respect to the group with a prior event. Patients were randomly assigned to 1 of 4 thrombolytic strategies. Baseline characteristics, 30-day outcomes, and 1-year mortality were compared between patients with (n = 6,704) and without (n = 34,143) prior myocardial infarction. Patients with prior myocardial infarction presented to the hospital earlier than those having their first event, but institution of thrombolytic therapy was delayed. Mortality at 30 days (11.7% vs 5.9%, p = 0.001) and 1 year (17.3% vs 8.2%, p < 0.001) was greater among patients with prior infarction, and independent of other demographic variables. Accelerated alteplase was more effective than streptokinase or combination therapy (30-day mortality 10.4% vs 12.2%, p = 0.012; 1-year mortality 15.9% vs 17.8%, p = 0.041). Infarct vessel patency did not differ between those with and without prior myocardial infarction (67.3% vs 67% at 90 minutes, p = 0.92); however, recurrent ischemia was more common in patients with prior myocardial infarction. Patients with healed myocardial infarction should be educated to ensure early hospital admission if they develop symptoms suggestive of acute infarction, and upon hospital arrival should be promptly triaged to receive reperfusion therapy with accelerated alteplase.
authors.affiliation: Department of Cardiology and the Joseph J. Jacobs Center for Vascular Biology, The Cleveland Clinic Foundation, Ohio 44195, USA.
authors.forename: D B
authors.initials: DB
authors.lastname: Brieger
authors.forename: K H
authors.initials: KH
authors.lastname: Mak
authors.forename: H D
authors.initials: HD
authors.lastname: White
authors.forename: N S
authors.initials: NS
authors.lastname: Kleiman
authors.forename: D P
authors.initials: DP
authors.lastname: Miller
authors.forename: A
authors.initials: A
authors.lastname: Vahanian
authors.forename: A M
authors.initials: AM
authors.lastname: Ross
authors.forename: R M
authors.initials: RM
authors.lastname: Califf
authors.forename: E J
authors.initials: EJ
authors.lastname: Topol
mesh_terms: D000368:Aged; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality; D015425:Myocardial Reperfusion; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D013300:Streptokinase / Q000627:therapeutic use; D016019:Survival Analysis; D015912:Thrombolytic Therapy; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D013300:Streptokinase